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From: Jeffrey M. Robbins, DPM


It is gratifying to see at least some comments on my original call for a single board. It is painfully obvious that change is hard and opinion strong on this topic. However, the future requires growth and development; otherwise it stays stagnant which will move us backward as the rest of the progressive world passes us by. We are only as good as our weakest link. Let’s make sure we have a high standard and strengthen all the links in our chain, keeping in mind that we are a procedure-based profession regardless of the simplicity or complexity of those procedures.


Jeffrey M. Robbins, DPM, Cleveland, OH

Other messages in this thread:



From: Ty Hussain, DPM


Responding to Dr. Udell's comment about dentists having multiple sub-specialties, its point is that they are able to maintain defined specialties mainly due to one factor: how they get reimbursed vs. the rest of the medical field. I have long said that dentistry was the smartest of all medical care due to the simple fact that the majority of the patients nationwide acknowledge that dental care is a cash transaction. Yes, there is dental insurance, but the majority of the population does not carry that, and dentists for the longest time have kept themselves out of the insurance rat race to keep it a cash business.


Therefore, you can have dental specialties that can charge so much money for a procedure, knowing they will be paid upfront. Can we say that about podiatric medicine, that has strived to be like our MD colleagues and wants to be part of every insurance to get reimbursed 80% of Medicare and be content? This is what causes that podiatric surgeon who wants to only perform ankle surgeries, but due to low reimbursement, wanders into general podiatric care. Our field is based on relying on third-party payors. Changing ourselves to a cash basis is a tough hill to climb.


Ty Hussain, DPM, Evanston, IL 



From: Doug Richie, DPM


Regardless of what type of practitioner today's podiatric resident "wants to be", the fact of the matter is that current podiatric residency training programs do not prepare residents to manage common musculoskeletal foot and ankle problems with non-surgical interventions. 


I believe this would fall under the scope of "general practice" podiatry which Dr. Sherman refers to. Dr. Jacobs uses the term "primary care podiatry" and cites the training current residents receive in the fields of rheumatology, dermatology, vascular disease, endocrinology, and neurology. How does training in these disciplines prepare the podiatric resident to evaluate and treat plantar heel pain and metatarsalgia, the two most common musculoskeletal conditions which present to the podiatric practitioner?


In this regard, Dr. Jacobs states that current residents have "excellent understanding" of biomechanics and kinesiology. If they do, this understanding came from 4 years of podiatric medical school and not from a 3-year surgical residency program. Even if this were true, training and hands-on experience in implementing non-surgical treatment of common musculoskeletal foot and ankle problems is sorely lacking in today’s podiatric surgical residency programs.  


Doug Richie, DPM, Long Beach, CA



From: Elliot Udell, DPM


Thank you, Dr. Zanbilowicz, for questioning what kind of studies should be enough to let us subject our patients to new and often expensive, out of pocket treatments. The article referenced from the New York Times is on target.


One way of determining whether a new, expensive product should get our clinical attention is whether major insurance carriers will pay for it. Peddlers of these products at medical conventions will argue with this point of view. Over the years, however, insurers such as Medicare and other major carriers will not pay for a treatment where the evidence supporting it is clinically questionable. Sometimes, when new research says that a treatment is questionable such as with ECSW therapy, Medicare stopped paying for it and dozens of shockwave providers ceased to exist. 


On the other hand, if a treatment is supported by large studies from many reputable study centers and the evidence is clear that the treatment will help patients, it will not be long before insurance carriers will be forced by public outcry to pay for it. So where does this leave us? In our practice, we may offer a new treatment that may be promising if it is inexpensive and, of course, safe. On the other hand, to our own financial detriment, we will not sell a treatment that will cost the patient "a thousand dollars" or more if the preponderance of evidence does not support it. 


Elliot  Udell, DPM, Hicksville, NY



From: Allen Jacobs, DPM


In 40 years of working alongside podiatric residents as a residency director and mentor, never have I heard any resident tell me that primary care practice represented their first choice. Never. Particularly now when we have outstanding three-year residencies and fellowships, I have yet to meet a resident who desired non-surgical practice at the completion of such training. I have long been a strong advocate of advancing education in the non-surgical aspects of podiatry and continue to do so. However, the comments of Dr. Sherman and his alleged survey results are simply not consistent with my experience in working with residents to this day.


I should further like to point out that as a result of the excellent training which our residents now receive, most...


Editor's note: Dr. Jacobs' extended-length letter can be read here



From: Jeff Root


Dr. Udell asks, “Should we deal with any orthotic lab that is owned by podiatrists, and is actively marketing their orthotics and training to chiropractors, physical therapists, and other non-podiatric professionals?" As the owner of an orthotic lab that doesn’t market to other specialties, I believe that podiatrists should do what they believe is in the best interest of their patients, even if that means using an orthotic lab that markets to other specialties. 


That said, I know of no other specialty that possesses the level and depth of education and training in non-surgical and surgical treatment of the foot and ankle and who also can provide other critical diagnostic tests and treatment such as imaging, prescription drugs, etc. While there are some individuals in other specialties who are very capable of providing good quality foot orthotic therapy, they do not possess the same range and quality of services that a podiatrist can provide. It is unfortunate that many consumers and patients do not understand the difference in the qualifications between podiatrists and other providers of foot orthotic therapy. That is why it is important to educate the public so they can determine who may be the best provider for their foot and ankle care.


Jeff Root, President, Root Lab, Inc.



From: Allen Jacobs, DPM


Dystrophic nail changes may be secondary to repetitive micro-trauma. Mallet toe and hallux hyperextension deformity are common examples of such etiologic factors. Fungal infection may occur as a comorbidity or without associated trauma. Dermatopathology laboratory testing can, in many cases, establish the fungal and or traumatic etiology and therefore suggest treatment options. I would suggest that such testing would be considered prior to EHL tenotomy for "spoon toe". Perhaps dermoscopy or other studies in the future will prove helpful.


Additionally, whether performed distal to the extensor hood or not, the development of flexion deformity of the hallux IPJ and hallux hammertoe are possible over the long-term. It seems appropriate to provide long-term clinical outcomes showing the absence of such iatrogenic deformity. Ultrasound, MRI, or other studies demonstrating re-establishment of the continuity and function of the EHL would also be appropriate. Long-term study of the eventual result with reference to the toenail appearance, texture, associated pain, etc. would also be helpful.


Dr. Katzen correctly notes that treatment of onychomycosis with laser therapy or the use of oral antifungals is not typically appropriate absent confirmatory testing. Furthermore, as noted by Dr. Katzen, any traumatically induced contribution to the observed nail dystrophy should be recognized and appropriate intervention offered to the patient. The induction period for iatrogenic deformity is not always immediate. Short-term success will not guarantee long-term success. 


Allen Jacobs, DPM, St. Louis, MO



From: Richard M. Cowin, DPM


Back in the 1980s, the federal government announced that they were seeking Preferred Practice Guidelines (PPGs) (aka Clinical Practice Guidelines) for all medical specialties for their National Guidelines Clearinghouse. In this announcement, they went one step further and stated that if the various medical specialties groups didn’t produce these on their own, the government would produce these documents for them. Doctors were rightfully concerned about how these untrained and informed bureaucrats might draft these documents and to their credit, many medical specialty groups went on to produce such guidelines.


The first podiatry organization to research, draft, and submit their PPGs to the National Guidelines Clearinghouse and to have such guidelines approved was the American College of Foot & Ankle Surgeons. However, the Board of Trustees for the Academy of Ambulatory Foot Surgery (now the Academy of Minimally Invasive Foot and Ankle Surgery) under the leadership of their then president, now prominent healthcare attorney, Lawrence Kobak, DPM, JD, felt that...


Editor's note: Dr. Cowin's extended-length letter can be read here.



From: Robert Scott Steinberg, DPM


Sorry, Dr. Trench, but I can't agree with your ideas! I own the foot. You want me to only own part of the foot. Added to that, we will spend the next 50 years explaining our fractured-in-half profession to patients and physicians. That's not going to happen. The residency program at Norwegian American Hospital, headed by Louis Santangelo, DPM, teaches both podiatric medicine and surgery. We have a three times a week foot and ankle clinic at the hospital. Residents also rotate through attendings' offices. In addition, Norwegian American Hospital hosts a twelve-slot family practice residency program, giving our podiatric residents further immersion in medicine. 


So, be careful before you break something.


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Dieter J Fellner, DPM


Dr. Epstein asks: “it is recommended that diabetic patients should have a baseline ABI performed? Recommended by whom, I ask?” 


Answer: The American Society of Vascular Surgery recommends that any diabetic patient aged 50+ should have baseline ABIs.


We perform ABIs accordingly and have the vascular surgery team visit the office for follow-up, as necessary.  


Dieter J Fellner, DPM, NY, NY

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